The Attitude of Medical Students Toward Voluntary Body Donation: A Single Institute Survey and Narrative Review of Global Trends

Introduction: Voluntary body donation (VBD) programs form the backbone of cadaveric teaching and learning in medical schools. It benefits the medical fraternity the most. Yet, there is a dearth of VBD practice among medical students. We aimed to understand the knowledge and attitude of first-year medical students in a tertiary institute with a systematic review of willingness toward VBD among undergraduate students worldwide. Methods: The first-year medical undergraduates were given a 12-item questionnaire to assess their knowledge and attitude toward VBD. Statistical tests were applied to analyze the difference between the variables. We systematically searched Google Scholar, PubMed, and SCOPUS databases until October 15, 2022. Data concerning knowledge, awareness, and attitude toward VBD among undergraduates of medical backgrounds were extracted and analyzed qualitatively. Results: A total of 82.5% of students returned the completed responses. A significant association was seen between their attitudes toward whole body donation by strangers (p=0.043) and family members (p=0.035). The religion of the participants significantly affected their opinions on VBD and their willingness to pledge themselves (p=0.034). For the review, 20 studies were selected to be analyzed qualitatively. These studies included 4232 undergraduate students globally who were assessed for knowledge, awareness, and attitude toward VBD. Around 50% of the studies were published in India. The first study included was published in 2008. Seven studies were exclusively conducted on medical undergraduates, while the rest consisted of a mixed cohort. The attitude and knowledge of medical undergraduates on VBD were assessed via questionnaires containing both open-ended and closed-ended questions. Conclusion: Based on observations from our survey and review, we concluded that while undergraduate students have a highly positive attitude toward VBD, their rate of pledging is low. The most prominent barrier to this attitude is their experience with cadavers in the dissection hall. Hence, we recommend a revisit of cadaver handling practices and the establishment of appropriate protocols for safe and deferential cadaver handling.


Introduction
Current technologies and multimedia techniques are gradually shifting contemporary anatomy teaching and learning methods toward an interactive module with less time focused on dissection [1,2]. These technologies include extensive use of audiovisual aids such as PowerPoint presentations (Microsoft Corp., Redmond, WA, USA), 3D animations, e-learning access via video designs, etc. [3,4]. The National Library of Medicine has created the Visible Human Project, a detailed anatomical representation of the human male and female body that is available as open source [5] and can be used as a reference aid for anatomy teaching. Another learning tool designed for practical/dissection-oriented learning is the virtual dissection table. It has enhanced touch interaction [6,7]. A comparative evaluation of the use of virtual dissection tables and cadaveric dissection in previous studies has concluded that these tables can be used in adjunct to classical dissection techniques for a better understanding of cross-sectional anatomy. The main drawback of using virtual dissection tables is that we will never encounter any anatomical variations, which is the uniqueness and challenge of cadaveric dissection [8]. Synthetic cadavers are superior-quality human simulation models that give a visual and tactile experience when learning anatomy [9]. Even with extensive use of technology, there is a common consensus that these advancements can accentuate the dissection model of anatomy learning but can never replace it [10][11][12][13].
Anatomy without dissection is like a boat without an oar. Dissection forms the most vital part of teaching and learning anatomy, as the basis of anatomy is learning as a three-dimensional concept [14]. It gives a visual understanding with long-term retention and enhances the learner's psychomotor domain of Bloom's taxonomy [15]. Autopsies also help discover anatomical variations that are necessary to avoid errors that occur during surgical treatment and to ensure proper management [16]. Dissection also enhances the development of compassion and provides human touch for developing empathy [17,18]. Many countries that initially replaced dissection with other technology later included it in their curricula, particularly for this reason [19].
The vitality of human cadavers as the pillars of safe medical and surgical practice is apparent, yet a shift towards alternate methods is rising over time. The prime reason is the shortage and non-availability of cadavers for dissection. The primary source of bodies for dissection is through voluntary body donation (VBD) programs and the procurement of unclaimed bodies [20]. Voluntary body donation is the selfless act of giving one's whole body after death for medical research and education [21,22]. Due to the high costs of virtual dissection tables and the growing number of medical universities in developing nations like India, VBD and the acquisition of unclaimed bodies continue to be the primary sources for studying anatomy [23].
Several initiatives are being taken by medical institutions globally to create body and organ donation programs [24][25][26]. The medical institutions work closely with various non-governmental organizations to create awareness and promote VBD among the general public [27]. Worldwide donors get high respect and honor as it is considered a sacrificial act for science. Body donors' families are felicitated in the gratitude ceremony [28,29]. Innovative awareness programs and the use of mass media to promote VBD are a few measures being implemented to address the scarcity of cadavers for dissection [30,31].
Even with these dynamic initiatives, the supply still needs to meet the demand. Studies have tried to analyze the barriers to VBD in general [31,32]. The VBD program benefits the medical fraternity the most. However, their willingness to use VBD for dissection is low [33,34]. The basis of anatomical knowledge for a first-year medical student is greatly enhanced by cadaveric dissection. This defines the significance of knowing how cadavers are procured for dissection. Therefore, we sought to comprehend first-year medical students' knowledge and attitude toward VBD by analyzing the facilitators and barriers faced by medical students globally regarding their willingness toward VBD.

Method for the original study
This study was approved by the Institutional Ethics Committee of the All India Institute of Medical Sciences, Bhubaneswar, India (approval no. T/IM-NF/Anatomy/22/85). The survey questionnaire was developed following a thorough examination of relevant literature on current attitudes and knowledge of VBD among medical students. It underwent validation by two subject experts separately. Subsequently, to assess the reliability of the questionnaire, it was administered to a small group of students to assess their comprehension of the questions. Any questions that posed difficulty for the participants were rephrased accordingly. Suggestions for possible improvements were considered, and further revisions were made to the questionnaire.
The questionnaire was administered through Google Forms (Google LLC, Mountain View, CA, USA) after receiving informed voluntary consent from the participants (see Appendix A). The first part of the questionnaire is related to the purpose of the assessment. The second part contains details about the participants, such as their names, ages, gender, and religion. This is followed by four questions in a dichotomous and semi-closed-ended format that assess the knowledge of VBD among first-year MBBS students. The questionnaire concludes with five questions that are a combination of the Likert scale, semiclosed-ended, and open-ended design to understand the attitude of first-year medical undergraduates toward VBD.

Statistical Analysis
To conduct the survey, convenience sampling was done based on the number of first-year MBBS students in the 2022 batch at our institute. The responses to each Likert scale question and other variables were summarized and described as numbers and percentages. All the decimals were rounded off to their nearest tenths or nearest whole numbers. The chi-square test was used to assess the differences among the different variables. A p-value of <0.05 was considered significant. Qualitative data obtained from responses to these semi-closed-ended questions were examined using an inductive qualitative method that involves open coding to discover emergent themes.

Objectives
This study aimed to evaluate the level of knowledge of VBD among undergraduates of medical backgrounds, assess the level of awareness and attitude toward VBD among medical undergraduates, and discover the facilitators and barriers toward the willingness to participate in VBD among medical graduates across the globe.

Protocol
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol was adopted. See Appendix B for the characteristics of the final 20 articles included in this study.
The review tried to survey the attitude of medical students worldwide toward VBD and recognize various factors in favor of or against it. This is a barrier and facilitator type of review to identify factors affecting the knowledge and attitude of medical graduates regarding VBD. The inclusion and exclusion criteria applied in the systematic review are given in Table 1.

Inclusion criteria Exclusion criteria
Population Undergraduate medical students, nursing students, paramedical students  The medical subject headings (MeSH) terms used in the search were: "Medical graduates, medical students, MBBS students, nursing students, paramedical students, voluntary body donation, body donation, self-body donation," "knowledge," "perception," and "awareness." These keywords were combined with Boolean operators (OR, AND). We did a comprehensive literature search using Google Scholar (38,200 articles), PubMed (175), and Scopus (27). We limited the articles to those published in the English language only. The articles that were common to all three databases were considered single. We conducted a thorough search of titles and abstracts. Articles that surveyed the perception of VBD among healthcare workers, medical doctors, or the general public only were excluded completely. Articles that were available in both were considered one. The records that were finally identified as eligible totaled 67. We screened the full text of these 67 articles and filtered 20 articles that met our criteria for the perception of various undergraduate students.

Data Extraction
Two independent reviewers gathered the data using a standardized form. Details of study design, year of publication, year of medical graduate, baseline, male:female ratio, age of students, sample size, place of study, the religion of the students, knowledge, awareness, and attitude toward VBD, and factors (barriers, facilitators) influencing VBD were recorded in a Microsoft Excel sheet (Microsoft Corp., Redmond, WA, USA). Outcome assessments were recorded in duplicate.

Original study
The Google forms were given to 120 students. Among them, 99 students returned the completed responses. There were 92 (92.93%) students in the age group of 17 to 19 years and 7 (7.07%) students in the age group of 20 to 23 years. Out of which, 25 (25.5%) students were females, and 74 (74.75%) were males. Analysis of the frequency distribution of students from different religions showed that 91 (91.92%) students were Hindus, 2 (2.02%) were Christians, 3 (3.03%) were Muslims, and 3 (3.03%) were atheists. The students' responses were analyzed, and the results are displayed in Table 2. A significant association was seen between responses to the question on attitudes toward whole-body donation by strangers. To this question, 85.71% of students who know someone who pledged to VBD responded positively (p=0.043, Table 2). A similar response was also found for the whole-body donation by a family member (p=0.035, Table 2). For the question on attitude toward whole-body donation by self, a significant difference in responses was observed based on the religion of study participants (p=0.034,

Characteristics of the Studies Included
After removing duplicates, 143 articles were identified in the initial screening according to the search strategy. Out of those, 76 papers dealing only with organ or blood donation were eliminated based on the title, abstract, and pertinent research question. Fifty articles were excluded where the study population was only healthcare personnel or the public. Twenty articles met the criteria we included for qualitative analysis.
These 20 articles were selected after full-text screening for undergraduate students' perception of VBD. These articles included undergraduates of medical backgrounds like MBBS students, nursing students, and paramedical students. Some of these studies have included healthcare staff like junior doctors, postgraduate students, technicians, even the public, engineering students, university students of mathematics along with undergraduate students of medical background [35][36][37][38][39][40][41][42][43][44]. We limited our analysis to the perception of undergraduate students in these studies. Among the 20, seven articles were identified with an exclusive study conducted on undergraduate students, including interns [45][46][47][48][49][50][51]. The undergraduate students' knowledge, attitude, and practice of VBD in all the articles mentioned above were included irrespective of their exposure to cadaveric dissection.
All these studies were carried out as cross-sectional studies with the administration of standardized and anonymous questionnaires, with one part dealing with demographic details (age, gender, ethnicity, nationality, religious belief, identified gender (if any), language spoken at home) of the participant. In contrast, other parts concentrated on the various aspects of knowledge, awareness, attitude, the willingness of the participant toward voluntary body donation, and attitude towards overall VBD (self, stranger, relatives). The characteristics of the study cohort (age, religion, gender distribution) are given in Table 3 and Figure 1. The questionnaires administered constituted open-ended and closed-ended questions for the participants to reflect on various parameters.

Sample size of cohorts included (total n=4232) Age of the study cohorts (in years)
Cahil et al. [

FIGURE 1: Gender and religious characteristics of the study cohort included in the systematic review represented as a percentage distribution
Seven out of these 20 studies conducted a pilot study on previous batches of students or random medicos, postgraduate students to assess the difficulty and clarity of the questions and to assess the time of response [39,42,43,45,48,50,52]. A team of subject experts later validated the questionnaires in the above studies before being administered to the target group. Two of these studies tested the reliability of the questionnaire based on Cronbach's α score [43,53].

Discussion
The present original study was conducted on undergraduate medical students on their entry into a tertiary healthcare institute. The age of the students ranged from 17 to 23 years. Saha et al. have also done their study on medical students in the age group of 18 to 22 years [38]. The questionnaire we gave the students was subdivided to understand their knowledge and attitude regarding VBD. Most of the students (87%) were aware of the process and purpose of VBD. These findings were similar to those reported by Kundu [42,21]. In the present study, their responses did not significantly differ according to age group, gender, religion, or if they were acquainted with a person who is a known donor. When analyzing the students' attitude toward VBD, a significant positive attitude and appreciation were seen towards donation by strangers (p=0.043) and family members (p=0.034) by the students who did not have a known person who pledged VBD. Such an association was not evaluated in the previous studies. This difference could be attributed to possible unpleasant experiences from a known person's body donation resulting in apprehension towards the act. Attitudes toward donation by self significantly differed based on religion (p=0.035). Atheists and most of the students who practiced Hinduism showed a positive attitude toward VBD when it came to pledging themselves when compared to those who practiced Islam and Christianity. Rokade et al. in their study, showed that according to their hospital data, most of the body donors were Hindus [36]. Like our study, they have affirmed the dominance of Hinduism in the VBD population. The other reasons they have attributed are the lower literacy rate and the more substantial effect of religion in other non-Hindu communities for the dismissive attitude toward VBD.

Knowledge of undergraduate medical students on VBD
Among the medical schools in 68 countries where human bodies are used for anatomy learning, only 32% of medical colleges use body donation as a source of cadaver resources. In the rest of the countries, it is primarily unclaimed bodies [20]. Looking at the global trends, Abbasi et al., in their study on 238 Iranian medical students, revealed that >70% were aware of VBD [48]. A study on the University College of Dublin students revealed that 43.2% of students were aware of the usage of cadavers for teaching and research purposes [47]. Most students (95.02%) from the School of Medical and Pharmaceutical Sciences of the University of Genoa, Italy, opined that cadavers are a fundamental source of learning and surgical training purpose [46]. When looking at the study by Jenkin et al., more than 70% of medical students accepted that cadaver donation is essential for medical education [43]. In contrast, in their study among the University of Nairobi Kenya residents, Mwachka et al. found that only 13.9% of undergraduate medical students were aware of the local body donation program [39]. They attributed this low awareness rate to insufficient awareness campaigns and orientation programs for undergraduate medical students. These results suggest that the awareness among medical students is higher in the countries where the source of cadavers is exclusively body donation programs than where the cadaver sources are unclaimed bodies in the majority. In the previous studies done on Indian students, it was found that >60% were aware of the purpose and mode of procurement of bodies in their medical schools [21,38,51,42,44,45,49].
The source of awareness among the students was broadly categorized into three groups: media (television, internet, newspaper, radio), family/friends, and medical persons. In the studies analyzed, it was observed that most of the students were aware of the process of VBD through medical personnel, followed by the media. Interestingly Abbasi et al., in their study, have shown that a significant number of medical students have said the primary source of their awareness was the Department of Anatomy, and the non-medical students attributed their awareness to media. Awareness through family and friends was comparatively lesser [48].

Attitudes toward and the practice of VBD among undergraduate medical students
We broadly divided the attitudes of undergraduate students toward VBD into positive, neutral, and negative. An extensive literature review showed that a student's attitude toward VBD is affected by various factors. Both global and Indian trends show an overall positive attitude among students, but there are some exceptions. Prameela et al., in their study, showed that only 6% of students were willing to donate their bodies for dissection [41] as opposed to 48% of students who showed a willingness toward organ donation. Though there is an overall positive attitude toward VBD, when opinion about donation is categorized into self, by a stranger, or a family member, the study by Mwachaka et al. revealed that 68.1% [39] were opposed to self-body donation and 59.2% recommended donation by strangers. One of the significant factors affecting the attitude is exposure to dissection. Many studies have shown that the students' opinions significantly varied before and after dissection [37,43,44,47,50]. After exposure to anatomy dissection, students significantly developed a negative attitude toward pledging VBD themselves and their families. However, Cahill et al. and Perry et al. showed that the attitude toward donation by a stranger did not change significantly even after exposure to dissection [47,52].
The practice of VBD was assessed in some studies by analyzing how many students pledged VBD. Compared to the high response rates towards willingness to body donation when the actual practice was analyzed, only a few students consented to VBD. The various studies and the number of students who pledged their bodies are given in Figure 2.

Facilitators
The studies included were analyzed, and the facilitators and barriers were grouped into common themes. Facilitator themes were education, gratitude to medical sciences, and motivation. Rokade [28,53].

Barriers
The willingness of donors toward body donation was high, but the actual practice of donating the bodies was significantly low, as seen in Figure 2. This disproportion could be due to the following barriers: disrespect in cadaver handling, damage to the body, religious beliefs, and discomfort to the family.
Lee (&) Lee found disrespect during cadaver handling as a significant barrier to VBD [53]. Karmakar et al. found that exposure to a dissection hall discouraged individuals against VBD [51]. Rokade et al. found that females had a negative attitude toward VBD compared to males because they thought their bodies would be disrespected during cadaver handling [36].
Lee (&) Lee reported damage or wastage of body parts as the second factor that needs to be addressed to change a negative attitude [53]. Several other studies in different parts of India have also raised a similar concern [39,40,41,44,45].
Religious beliefs are a major barrier worldwide toward VBD. Ciliberti et al. pointed out that students who were not religious were 5.9 times more likely to donate their bodies [46]. Most of the studies revealed that religion was a significant barrier [39,40,41,45,46,21,43]. Discomfort to the family members prevented the donors from VBD, as detailed in many studies [38,41,46,21,43]. Mistrust against health services was another significant barrier for VBD, as pointed out by Rokade et al. and Prameela et al [36,41].

Limitations of the original study
Although the questionnaires assessed the overall attitude of the first-year undergraduates toward VBD, they did not assess the actual practice. The cohort was confined to first-year MBBS students only. Comparison with other senior students and postgraduates who had been exposed to dissection and clinical postings for some time now will help analyze the factors responsible for the change of attitudes and practice if any. Analysis of the VBD initiative by faculty and other staff of the Department of Anatomy was not assessed to see if it had any influence on the attitudes and practice of VBD among medical students. The questionnaire scale should have been validated against previously existing scales.

Limitations of the review
This study was done on a relatively limited number of databases for the identification of potentially eligible studies. The assessment of study quality was limited as objective scoring was not done.

Conclusions
The present study has shown that the religion of the students and the presence of a known person who donated their body significantly affected their attitudes toward VBD. The original study and the review of relevant literature have shown a positive attitude among medical students toward VBD. However, the change of attitude into actual practice in later life is very low. Based on our observations, we arrived at suggestions to improve the current scenario of students' attitudes toward and practices of VBD. Special training and educational sessions should be organized for undergraduates to increase awareness. A gratitude ceremony for dissected cadavers conducted for students, the dissection staff, and faculty members may help reduce the negative attitude toward VBD after exposure to dissection. Guidelines for the safe and respectful handling of each cadaver used in dissection must be established. Cultivation of an altruistic attitude during the foundation course for students is essential. Media plays a significant role in creating awareness. And so, multimedia should be used effectively to create awareness of the cultural acceptability of VBD.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.